Pneumonia in Children

Aka: Pneumonia in Children, Pediatric Pneumonia, Community Acquired Pneumonia in Children

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II. Epidemiology

  1. Incidence
    1. Worldwide: 155 million cases annually (and 2 million deaths under age 5 years)
    2. Pneumonia is the most common cause of hospitalization in children
  2. Immunization (esp. Prevnar, Hib Vaccine) has dramatically cut the number of childhood Pneumonia hospitalizations
    1. Pneumococcal Pneumonia hospitalization cases dropped by half after PrevnarVaccine introduced
    2. Olarte (2017) Clin Infect Dis 64(12): 1699-1704 [PubMed]

III. Causes

  1. See Pneumonia Causes in Children
  2. Viral Pneumonia accounts for 80% of cases in under age 2 year old children
  3. Hospitalized Children
    1. Viral Pneumonia (66%)
      1. Respiratory Syncytial Virus (esp. under age 4 years)
      2. Human Rhinovirus
      3. Adenovirus (esp. age <2 years)
      4. Human Metapneumovirus (esp. age <10 years)
      5. Coronaviruses (includes Covid19)
      6. Influenza Virus
      7. Parainfluenza VIrus
    2. Bacterial Pneumonia (8%)
      1. Atypical Pneumonia (>3%)
        1. Mycoplasma pneumonia (esp. age >4 years old)
        2. Chlamydia pneumoniae (infants)
      2. Streptococcus Pneumoniae
      3. Staphylococcus Aureus
      4. Streptococcus Pyogenes

IV. History

  1. Age suggests cause and management
  2. Immunizations deficient
    1. Streptococcus Pneumoniae
    2. Haemophilus Influenzae
    3. Pertussis
  3. Recent hospitalizations
    1. Nosocomial Pneumonia
  4. Day care attendance
    1. Viral Pneumonia
  5. Contagious contacts
    1. Viral Pneumonia
    2. Mycoplasma pneumonia
    3. Tuberculosis
  6. Travel
    1. Influenza
    2. Severe Acute Respiratory Syndrome (Asia)
    3. Fungal Infection
      1. Blastomycosis
      2. Coccidioidomycosis (Southwestern U.S.)
      3. Histoplasmosis (Ohio and Mississippi River Valleys)
  7. Recent Antibiotics
    1. Consider Antibiotic Resistance (e.g. PRP)
  8. Comorbid conditions
    1. Cardiopulmonary disease (e.g. Cystic Fibrosis)
    2. Immunodeficiency (e.g. Asplenic)
    3. Neuromuscular Disease
  9. Possible Ingestion
    1. Foreign Body Aspiration
    2. Toxin Ingestion

V. Risk Factors

  1. Young age
  2. Male gender
  3. Tobacco exposure
  4. Pollution exposure
  5. Child care attendance
  6. Malnutrition
  7. Immunodeficiency
  8. Anatomical airway anomalies
  9. Underlying metabolic disorders

VI. Precautions

  1. Occult Pneumonia should be considered in the following cases
    1. Fever for more than 5 days (especially if over 39 C)
    2. Leukocytosis with White Blood Cell Count over 20,000
    3. Abdominal Pain
      1. Presenting complaint in 8.5% of patients, age 3 to 14 years old (esp age <5 years)
      2. Vomiting or Diarrhea is present in 27% of cases
      3. Broder (2022) Crit Dec Emerg Med 36(1):11-2

VII. Symptoms

  1. Fever
  2. Respiratory symptoms (see signs below)
    1. Cough
    2. Tachpnea
    3. Dyspnea
  3. Lethargy
  4. Irritability
  5. Decreased oral intake
  6. Dehydration (e.g. decreased Urine Output)
  7. Vomiting
  8. Diarrhea
  9. Abdominal Pain

VIII. Signs

  1. Pneumonia unlikely without fever and Tachypnea
    1. Consider Chlamydia TrachomatisPneumonia in under age 3 weeks if affebrile with Staccato Cough
    2. Consider Mycoplasma pneumonia in older children with malaise, Sore Throat, fever and indolent course
  2. Findings highly suggestive of Pneumonia
    1. Fever
      1. More commonly >101.3 F in Bacterial Pneumonia
    2. Cyanosis
    3. Respiratory distress (one or more of the following)
      1. Respiratory Distress in Children with Pneumonia
      2. Tachypnea
        1. Absence of tachpnea when fever is present has strong Negative Predictive Value
        2. Tachypnea is common with fever and therefore has poor Positive Predictive Value
      3. Cough
      4. Nasal flaring
      5. Intercostal retractions
      6. Grunting
      7. Rales
      8. Decreased breath sounds

IX. Differential Diagnosis

  1. See Pneumonia
  2. Head and neck disorders
    1. Otitis Media
    2. Rhinorrhea
    3. Nasal Polyps
    4. Pharyngitis
    5. Upper Respiratory Infection
  3. Respiratory conditions
    1. Asthma
    2. Bronchiolitis
    3. Bronchitis

X. Labs: Efficacy

  1. Tests that are helpful
    1. Rapid viral Antigens
      1. Influenza Immunoassay
      2. Covid19 PCR
      3. RSV Test
        1. Not indicated in classic presentations (obtain if unclear diagnosis)
    2. Oxygen Saturation (if respiratory distress)
  2. Tests helpful in severe cases (low yield if moderate infection)
    1. Gram Stain
    2. Blood Culture
  3. Tests possibly useful in retrospect (identify outbreak)
    1. Mycoplasma pneumoniae titer
    2. Chlamydia pneumoniae titer
  4. Tests which are usually not helpful for diagnosis (but may be used for trending in the inpatient setting)
    1. Complete Blood Count (CBC)
    2. C-Reactive Protein (CRP)
    3. Erythrocyte Sedimentation Rate (ESR)

XI. Labs: Inpatient

  1. Rapid viral Antigens
    1. Influenza test
    2. RSV test
    3. Covid19 PCR
    4. Respiratory Panel (consider)
  2. Sputum Culture and Gram Stain
    1. Difficult to obtain in children
    2. Low yield
  3. Blood Culture and Gram Stain
    1. Identifies pathogen in 2 to 7% of hospitalized cases
  4. Complete Blood Count
  5. C-Reactive Protein (CRP)
  6. Erythrocyte Sedimentation Rate (ESR)
  7. Procalcitonin
    1. Procalcitonin <0.25 ng/ml suggests non-Bacterial Pneumonia (may reduce Antibiotic use)
    2. Tsou (2020) Infect Dis 52(10): 683-97 [PubMed]
    3. Stockmann (2018) J Pediatric Infect Dis Soc 7(1): 46-53 [PubMed]

XII. Imaging: Chest XRay

  1. Indications
    1. Inpatient
    2. Unclear diagnosis
    3. Prolonged Pneumonia or not responding to Antibiotics after 48 to 72 hours of treatment
    4. Pneumonia complications
    5. Hypoxia
  2. Findings
    1. Lobar consolidation
      1. More common in Bacterial Pneumonia
      2. May be seen in viral pneumona
    2. Interstitial Infiltrates
      1. More common in Viral Pneumonia
      2. May be seen in Bacterial Pneumonia
  3. Precautions
    1. Chest XRay is not needed to confirm Pneumonia in the outpatient setting
      1. History and exam may be sufficient to make a Pneumonia diagnosis
    2. Chest XRay does not differentiate virus from Bacteria
      1. Significant overlap of xray findings in cases of Pneumonia, Bronchiolitis, Asthma Exacerbation
    3. Chest XRay may be normal in early Pneumonia
    4. Chest XRay may be abnormal for 3-6 weeks after diagnosis

XIII. Imaging: Other

  1. Lung Ultrasound (POCUS)
    1. Detects lung consolidation, Parapneumonic Effusion, empyema
    2. Sufficient to diagnose Pneumonia with good Test Sensitivity
    3. Jones (2016) Chest 150(1): 131-8 [PubMed]

XIV. Management

  1. See Pneumonia Management in Children

XV. Disposition

  1. See Pneumonia Management in Children

XVI. Complications: Parapneumonic Effusion

  1. See Pneumonia for other complications
  2. Indications for drainage
    1. Symptomatic
    2. Pleural Effusions >10 mm on lateral XRay
    3. Pleural Effusion >1/4 of hemithorax

XVII. Prevention: Immunization

  1. Primary Series
    1. Rubeola (MMR Vaccine)
    2. Varicella Zoster Virus
    3. Pertussis (DTP Vaccine)
    4. Haemophilus Influenzae Vaccine (Hib)
    5. Pneumococcal Conjugate Vaccine (Prevnar)
  2. Booster and periodic Vaccinations
    1. Influenza Vaccine yearly
    2. Pertussis (DTaP Vaccine)
  3. High risk infants
    1. Palivizumab (Synagis)
  4. Pregnancy
    1. Diphtheria and PertussisVaccine (Tdap Vaccine)
      1. Given at 27 to 36 weeks in each pregnancy
      2. Allows for passive Immunity for newborns
      3. (2017) Obstet Gynecol 130(3): e153-7 [PubMed]

XVIII. References

  1. Bradley (2011) Clin Infect Dis 53(7): e1-52 [PubMed]
  2. McIntosh (2002) N Engl J Med 346:429-37 [PubMed]
  3. Nelson (2000) Pediatr Infect Dis 19:251-3 [PubMed]
  4. Ostapchuk (2004) Am Fam Physician 70(5):899-908 [PubMed]
  5. Smith (2021) Am Fam Physician 104(6): 618-25 [PubMed]
  6. Stuckey-Schrock (2012) Am Fam Physician 86(7): 661-7 [PubMed]

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